Bioethical concerns are global, bioethics is Western

Abstract

Modern bioethics was born in the West and thus reflects, not surprisingly, the traditions of Western moral philosophy and political and social theory. When the work of bioethics was confined to the West, this background of socio-political theory and moral tradition posed few problems, but as bioethics has moved into other cultures - inside and outside of the Western world - it has become an agent of moral imperialism. We describe the moral imperialism of bioethics, discuss its dangers, and suggest that global bioethics will succeed only to the extent that it is local.

Is bioethics a Western phenomenon?

The issues that fall under the purview of bioethics - doing good, avoiding harm, respecting people and their communities, justice - are of concern to all those who share life on the earth, but their articulation - in research institutions, health care centers, corporate boardrooms, and governmental policy - has the strong accent of the West. While a Western-accented bioethics has its uses - for example, it simplifies the globalization of medical research and drug development - it ignores moral traditions whose roots and ways of thinking lie outside of the Western philosophy and political and social theory. There is an interesting irony here: in order to make bioethics global, it must be local.

Bioethics and diverse moral traditions

After their research trip to China in 1984, Renée Fox and Judith Swazey returned to the United States and declared, `Medical morality is not bioethics.' Their observation - that bioethics as developed in the United States was simply one among many possible incarnations of medical morality - was not warmly received (see, e.g., Gorowitz, 1986). In the intervening years, however, there has been a gradual but growing recognition that the discipline of bioethics, assembled in the North American and European cultural context from the raw materials of Western moral philosophy, may not fit all of the world's cultures. And yet today, most, if not all, of the efforts to make bioethics more `culturally appropriate' amount to little more than adapting Western bioethics to varied cultural settings.

We are aware of the danger of putting a determinative adjective `Western' to an area of systematic study or knowledge. After all, there is nothing called `American anatomy' or `British biochemistry' or `Western pathology'. Why then should we, or anyone else, think of bioethics as Western? Bioethics, as conceived of in most discussions, is Western not because it originated in the United States or has its roots in the West, but because of the way it is theorized, structured, formulated, and practiced. We are not alone in this view of bioethics. Alora and Lumitao (2001) declared that we should move `Beyond Western Bioethics' and Myser (2003) described the `normativity of whiteness' present in mainstream bioethics discourse. Further testimony to the `color-blind' bias in bioethics is found in what Arekapudi and Wynia (2003) call the `unbearable whiteness' of mainstream bioethics and in Burton's (2007) concern that `bioethics cannot figure out what to do with race.' Taken together, these critics confirm that the dominant socio-cultural-moral construct known as bioethics does not encompass the belief-systems, cultural norms and moral values of people who are located outside of the moral tradition that evolved in white Western societies.

Diversity is undeniable reality - and an asset - of contemporary life. We share the planet with more than 6 billion people who speak over 6000 languages, live in about 200 countries, and belong to a number of religious and/or spiritual traditions. The technologies of communication, the global nature of market economy, and increased opportunity and ability to travel have made multi-faith, multi-lingual, multi-cultural societies commonplace. Given that the purview of bioethics extends from personal issues (e.g., how should one live ethically as a healthcare professional?) to global concerns (e.g., what should our governments and international organizations do to combat bio-terrorism?), one would expect this field to be characterized by a broad moral vision, extensive intercultural dialogue, and a rich variety of perspectives.

This is, however, clearly not the case. For many scholars, Bioethics is a blinkered discipline, seeing the world - its issues, problems, and solutions - through eyes coloured by the noble, but limited, philosophical traditions of the West. Cases in point are many; a few may suffice.

Most histories of medical ethics - and especially those that are foundational for bioethical thought - begin with the Oath of Hippocrates. How many bioethicists are aware that the Oath in Charaka Samhita in Ayurveda surpasses the Hippocratic Oath in both `eloquence and moral idealism' (Jonsen, 2000)? Where are the references to the two most ancient but living systems of medicine - Hindu medicine of Ayurveda and ancient Chinese medicine - and their medical ethics in bioethics discourse? Interestingly, although bioethics emerged as a check on value-free, objective Western medical science, it is itself a product of modern Western medicine and thus pays scant, if any, attention to other healing traditions. Complimentary and alternative medicine (CAM) or traditional indigenous systems of medicine are practiced in vast areas of the world and, to be sure, have gained popular recognition even in the West in recent years, but are seldom discussed in the bioethics literature (Turner, 2004). It is no surprise then, given this limited worldview, that mainstream bioethics does not know what to do and how to deal with Ayurveda or acupuncture or other traditional systems of medicine, aside from using them as esoteric puzzles. Having no place for these non-Western traditions, the discourse of bioethics is impoverished indeed.

Consider too the role of moral, political, and social philosophy in bioethics. Unless stated otherwise, philosophy for most scholars means Western philosophical systems of thought in bioethics. It is not surprising then, that bioethics discourse is replete with Socrates, Plato, Aristotle, Augustine, Aquinas, Kant, Locke, Mills, Bentham, Heidegger, Levinas, Sartre, and Foucault. Most mainstream bioethicists would be baffled if Buddha, Confucius, Charaka, Sushruta, Shankara, Ramanuja, Chaitanya, Ramakrishna, Vivekananda, Gandhi, Gibran, Radhakrishnan, Tagore, Aurobindo, or Sri Anukulachandra were introduced into the philosophical conversation that grounds bioethics. Most of these thinkers will, in fact, be unfamiliar to Western bioethicists.

Putting moral traditions in their place

Please do not misunderstand us: we are not jumping on the `anything-Western-is-evil' bandwagon. We deeply value and appreciate the contribution of Western philosophy to bioethics. Our question is simply: why do bioethicists coming from Western theology, philosophy, and ethics ignore the significant religious/spiritual and philosophical systems that developed in other places and cultures? Is it ignorance or is it ethnocentrism? Have bioethicists unconsciously divided the world into the “Western” and the “Oriental” (Said, 1978) or “Western” and “abnormal” (Hern et al. 1998)? Ignoring non-Western moral ideas can perhaps be justified for those whose work is intended only for others who sit squarely in the Western tradition, but in an increasingly pluralized world, this is less and less common. It is an interesting paradox that popular culture in the West is flooded with literature regarding Eastern religion and spirituality while the discourse of mainstream bioethics is conspicuous by its near-exclusion of Eastern worldviews. Furthermore, the educational programs created to train non-Western health care workers and researchers in bioethics (`medical morality'?) rarely make the effort to discover, teach, and integrate these other moral traditions, raising the question of the `colonizing' nature of otherwise well-meaning ethics training programs (Coward and Ratanakul, 1999).

The Western approach to bioethics gives rise to a `one-size-fits-all' set of `principles.' Distinguished professors seek to train the future bioethicists of the (so-called) developing world in the acrobatic art of balancing the `principles' (in either their American or European version) to conquer the most troubling of ethical dilemmas. While the `principles' are often framed as meta-cultural, they derive from Western secular belief-systems that are not responsive to either the cultural ethos and moral sensibilities of ethnic minorities of the West or the emotional needs and religious/spiritual worldviews of people in the non-Western world. It is important to remember that the moralities of both Western and non-Western cultures are born out of the interplay of values, cultural norms, belief-systems, and moral traditions that evolved in a variety of historical settings. Application of a set of `principles' - even when those principles are `adjusted' to the recipient culture - fails to engage with the moral ideas and with the medical systems in non-Western cultures (Stonington and Ratanakul, 2006) and thus fails as a strategy for promoting more ethical care.

Consider autonomy, the dominant principle of bioethics in the United States (Wolpe 1998). It is difficult for some Western bioethicists to realize that the principle of individual autonomy - even when tweaked to fit in non-United States settings by relocating autonomy in the family, or the clan, or an elder - is an assault on the tradition and values of non-Western societies who believe in the matrix of relationships in dynamic equilibrium of the cosmos. Or, consider the language commonly used in bioethics such as `end-of-life'. This term, so widely accepted in the West is heard and apprehended much differently by a traditional Hindu who believes in `life after death'. The complex and rich realities of cross-cultural bioethics discourse are blurred by uncritical application of the language, methods, and `universal principles' of the modern Western philosophical framework. Furthermore, it is inappropriate, and yes, unethical to impose, either consciously or unconsciously, the dominant Western socio-cultural-moral construct to ethnic minorities in the West and the vast non-Western world. Our criticism may sound exaggerated, but there are bioethicists who defend their `moral imperialism' (Dawson and Garrard 2006), failing to see this cultural invasion as unethical.

The blindness to the cultural diversity and other religious/spiritual/moral/philosophical traditions of the world extends to the well-intentioned efforts of those who seek to serve those in the `developing' countries. The `Universal Declaration on Bioethics and Human Rights' promulgated by UNESCO offers an example. One of its articles says, `The interests and welfare of the individual should have priority over the sole interest of science or society' (UNESCO, 2005). We respect the intent of this proclamation but question its `universality'. This `universal' declaration could be read to contradict the cultural norms and moral values of a major part of the world and question the foundations of several Eastern religious and spiritual traditions. From the perspective of billions of people in the non-Western world, the idea that `the interests and welfare of the individual should have priority over the sole interest of science or society' is not just absurd, it is dangerous. Taken at face value, it makes the whole public health enterprise untenable on ethical grounds. The Declaration does also include articles on solidarity, and on respect for cultural diversity and pluralism, which can be read to balance the individual focus. The elaboration of the framework principles needs a lot of further work in different cultures and communities.

Part of the problem here is that bioethics - coming from the Western humanist tradition - is focused on `rights.' Underemphasized in bioethics is the fact that a `right' unaccompanied by a `duty' makes little, if any, sense. Moreover, in many non-Western societies, the notion of duty is historically held in high regard making rights-based bioethics something distant, alien, and discordant with the local ethos. It is interesting that in the Eastern world-view, there are no segregated, airtight compartments of religion, philosophy, spirituality, ethics, politics, and science. Knowledge is whole, Truth is One, and in the relational nature of life, the goal is synthesis and harmony rather than analysis and division. In the Eastern tradition, there is no divergent dichotomy between faith and reason in the pursuit of knowledge and in the quest for truth. The rigid division between `religious' and `secular' is also artificial: in Eastern philosophy, human beings are on a continuous journey of inner realization from a lower level to a higher level of truth.

Bioethics and justice

Bioethics loves to talk about distributive justice, but ironically bioethics is part and parcel of the injustices of the Western health care industry. At present the bioethics market in the West is so full of different varieties of colourful `cakes' for its wealthy customers (pre-implantation genetic diagnosis, neural enhancement, genethics, nanotechnology, etc.), that few notice the lack of `bread' (i.e., issues of social inequality in health, poverty, basic health care, AIDS, violence, etc.) for the vast majority of the poor and needy. Given its comfort with institutionalized medicine and its occupation with procedures, rules, rights, and legal frameworks, armchair bioethics now faces the danger of being reduced to bio-etiquette with philosophy as its feel-good companion.

Mainstream Western bioethics is occupied with the obsessive pleasure solving esoteric ethical dilemmas and conflicts and with categorizing the priority of `rights'. While deriving solutions to enigmatic puzzles can be intellectually satisfying, it is an emphasis that turns the field inward. Bioethics - in the West and the East, the North and the South - will flourish if it makes room for the moral traditions of other cultures. Imagine the possibilities if bioethics could be shaken from its Western view of reality to consider the perspective on reality found in dharma. This ideal-centric way of life focuses on `being and becoming' and sees human beings interacting with their environment in a cosmos guided by the principle of `live and let live'. This approach offers a way to get beyond the apparent irreconcilable rift between the `religious' and the `secular' in the West. It describes a harmonious way of life help where we human beings - all of us driven by a similar urge to love and be loved - are deeply embedded in a matrix of interdependent relationships that tie us together.

In an international roundtable meeting on Bioethics, one of us asked delegates from different Asian and European countries how they felt about the current Western-model and its limited vision of bioethics. The response of one Asian delegate still haunts us. She confided, “You know, they have the power, they have money, they set the agenda!” It is time to stop and ponder this.

Modern bioethics is largely conceived of as Western, but bioethical concerns are global, as shown in the discussions of regional associations such as the Asian Bioethics Association. It is better to accept this reality now, rather than deluding ourselves with wishful thinking and exporting a modern Western philosophical framework to fit in all non-Western cultures. Our view, a voice from the margins of the main stage of bioethics, is shared with the hope that some day bioethics will come out of its self-imposed confinement of `the Western-view-is-the-only-credible-one' mind-set to see the much bigger, more colourful and rich global arena where global bioethics must first be local.

Bioethics needs to expand its vision and to open its way of thinking to the whole of humanity. Only then can we face the challenge of finding the common ground of morality across different cultures that acknowledges and respects other faiths and other philosophical and moral traditions. Are we prepared to face this challenge?